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Patriot Program Evaluation

RST 672
Shenandoah University, Spring 2014

by
Christina R. Shaffer

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Section 1: Description of the program

The Patriot Program at MM Pierce Elementary School was begun during the 2011-2012
school year. Open to any student in grades preschool through fifth grade, the goal of the
program is to teach community service; build a foundation of knowledge in American history,
symbols, and music; and ultimately help participants establish a sense of patriotism and good
citizenship. The program was created and is organized by the school principal with assistance
from the school bookkeeper/secretary who provides help with recording and organizational
materials. When creating the Patriot Program, the principal based the formation upon a similar
program that she had heard about through a family member at another school. She contacted
the principal of the other school to inquire and acquire information, resulting in the start of the
program at MM Pierce Elementary.
Details of program requirements vary by student grade level and are available to the
students upon request of indicated interest and also to the parents via Blackboard (Appendix
A). Each requirement has an assigned due date indicated and is either submitted or checked off
(based on the details) by the principal. This is an extra-curricular program in which all
assignments are expected to be done independently from the school. However, knowing that
there are some students who are unable to receive the assistance needed at home to do so, the
Patriot Club was formed as a branch of the Patriot Program. The Club meets before school,
approximately once a week, and allows the participants the opportunities to complete the
program assignments there, if needed, under the direction of school-employed instructional
assistants who are in charge of the organization of the club.

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For the 2013-2014 school year, there are fifty-four students who are enrolled in the
Patriot Program. Of this total number, two students are preschoolers, seventeen are
kindergarteners, thirteen are first graders, nine are second graders, seven are third graders,
three are fourth graders, and three are fifth graders. The primary stakeholders include these
fifty-four students (being participants) and the principal (being the coordinator of the program).
The parents of the involved students are important stakeholders, but not viewed as primary
ones as they are indirectly versus directly involved. The instructional assistants who lead the
Patriot Club are also important stakeholders, but as this evaluation pertains to the Patriot
Program versus the Club, they are not viewed as primary either.
At the start of the 2013-2014 school year, the school had 529 students currently
enrolled: 62 African-American, 64 Hispanic, and 403 Caucasian or unidentified. Thirty-one of
these students were enrolled in the English-as-a-Second-Language (ESL) program and 70
students had an Individualized Education Plan (IEP). Approximately 201 students received free
or reduced lunch. The survey that was given to 28 program participants, included 10 males, 15
females, and 3 students who did not respond to the gender question. Also, of these
respondents, 19 indicated their race as Caucasian, 4 as African-American, 2 as Hispanic, 1 as
Other, and 2 did not respond to the question.

Section 2: Detailed logic model of program components

The logic model (Figure 2.1) for the Patriot Program presents an overview of the
involvement (inputs), assignments (activities), program occurrences (outputs), and expected
results (outcomes). For the program to function successfully, it is assumed that parents will be

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willing to help their children complete the requirements indicated per grade level, as there are
some that the children cannot do without adult supervision and/or assistance. Being an extracurricular activity, not a mandatory program, it is also assumed that the students will be
interested in enrolling in the program. Without presenting an interest to the students, the
program would cease to exist. With the Patriot Club being held at school to allow for student
assistance in completion of Patriot Program tasks, the last assumption is that students who are
unable to receive assistance at home would be able to attend club meetings and activities. It
should be noted that the club meets prior to school hours requiring transportation
arrangements to be made and specific parental/guardian permission to be granted.
For the Patriot Program, there are six inputs. There need to be preschool through fifth
grade students who participate. The parents of the involved students have to commit to
assisting in the completion of at least some of the tasks. The principal, as the creator and the
coordinator of the program, has an involvement in organizing and assuring that participants are
following program guidelines and completing tasks by specific due dates. The Patriot Club, as a
supplement to the Patriot Program, provide opportunities for students to complete tasks if the
parental involvement is not feasible. The time given by the parents, the students, the principal,
and the instructional assistants who lead the Patriot Club is a widely-applicable input. For the
program to be completed adequately and successfully, the participants (and those who help
them) must have access and familiarity to the program guideline documents. All of these inputs
lead to the activities.

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Figure 2.1

Program: Patriot Program Logic Model Location: MM Pierce Elementary School Model by: Christina Shaffer

Outputs

Inputs
Activities

Parental
s
Involvement

Patriot Club

Memorization and
Comprehension of
Pledge of Allegiance
and Patriotic Songs

PK-5th Grade
Students
Principal
Program
Guidelines
Documents

Creation and
Recognition of models,
flags, symbols, maps,
officials, and reports

Time

Outputs

Short

100% of Program
participants can
recite the Pledge of
Allegiance from
memory

Demonstration of
Patriotic traditions

100% of Program
participants can
explain various
Patriotic songs,
symbols, and
geography; as well
as identify local and
national officials
based on gradelevel assignments

Application of
knowledge of
American and
Virginia history,
familiarity of
American and
Virginia geography

Performance of
Community Service
100% of Program
Participants
participate in
community service
activities

Understanding of
community service
needs and ability to
help

Outcomes
Medium

Long

Appropriate
responses in
Patriotic situations
outside of school
events
Providing
explanations and
understanding of
Patriotic traditions
and importance of
historic landmarks
Recognition of public
officials and their
offices in non-school
assignments/tasks

Involved citizens in
civic opportunities
and settings

Increased
understanding of
local and countrywide geography

Continued
participation in
community service
events/activities

Assumptions

External Factors

Parents will be willing to help their children complete the requirements for the
program. Students will be interested in enrolling in the program. Interest will
continue through the completion of the program. Students unable to complete the
program requirements at home will be able to do so at the sponsored Patriot Club.

Many students are in childcare situations after school, limiting parental time to assist.
Economic situations: the families may not be able to afford materials to complete some
projects. The Patriot Club meets before school: students would need transportation not
provided via school bus. Students may be interested, parents may be unwilling.

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The activities associated with the Patriot Program can be grouped into three main
categories: 1) memorization and comprehension of the Pledge of Allegiance and patriotic
songs; 2) creation and recognition of models, flags, symbols, maps, officials, and reports; and 3)
performance of community service. Memorization of the Pledge of Allegiance and community
service action is applicable to every grade level. Second through fifth grade participants all have
tasks involving a patriotic song. The creation and recognition tasks are applicable in varying
forms for every grade also. These activities do not have to happen in a specific order, but just
need to be completed prior to their assigned due date.
The first activity (memorization and comprehension of the Pledge of Allegiance and
patriotic songs) should result in the output of 100% of the Patriot Program participants being
able to successfully recite the Pledge of Allegiance, as well as, 100% of the participants knowing
and explaining various patriotic songs, depending on their grade level task. Creation and
recognition of models, flags, symbols, maps, officials, and reports (the second activity) should
have the output of 100% of participants being able to explain and identify various patriotic
symbols, identify local and national officials, and a familiarity with local and national geography,
again based on their grade level task. All participants are required to perform community
service (the third activity), presumably resulting in 100% of program enrollees participating in
this task.
The outcomes for the Patriot Program are divided into short, medium, and long term. By
participants being able to recite the Pledge of Allegiance from memory, the short term result
would be an ability to demonstrate patriotic traditions, which is shown specifically through an
assembly held at the school. Applying knowledge of American and Virginia history, familiarity of

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American and Virginia geography would be a short term outcome of the participants being able
to explain and identify symbols, geography, and officials. Participation in community service
activities lead to the short term outcome of an understanding of community service needs and
the ability of how individuals are able to help.
Medium term outcomes include being able to appropriately respond in patriotic
situations outside of school events (such as knowing what to do when the National Anthem is
played at a baseball game). This would be a direct correlation from the short term outcome of a
demonstration of patriotic traditions. Providing explanations and understandings of patriotic
traditions and the importance of historic landmarks is a medium term outcome that results
from the demonstration of patriotic traditions, also. The application of knowledge of local and
national history and geography leads to a medium outcome of providing explanations and
understanding of patriotic traditions and the importance of historic landmarks, the recognition
of public officials and their offices in non-school assignments/tasks (such as on the evening
news), and an increased understanding of local and country-wide geography. Understanding
the needs of community service and how to help should lead to a medium outcome of
continued participation in community service even after the Patriotic Program is completed. All
of the medium outcomes lead to the ultimate goal, the long term outcome, of producing
involved citizens in civic opportunities and settings.
There are some external factors that should be considered. Many of the students at MM
Pierce Elementary are in childcare situations after school, limiting the parental time available
for them to assist their children in completion of tasks. It is also a mid-to-low economic area
and several families may not be able to afford the materials needed to complete some projects.

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The Patriot Club, as previously mentioned, meets before school which means that students
would have to have transportation since county-provided school buses would not have arrived
in time. Some of the students may be willing and interested in participating, but their parents
may not be willing to allow them to participate or willing to help.

Section 3: three program specific questions that the evaluation will answer/address
Question 1: Are the participants satisfied with the program?
This evaluation question focuses on outcomes of the program using quantitative data
obtained from close-ended survey questions (Appendix B). This method was chosen for data
acquirement because the students responding to the survey are of an elementary age and a
close-ended response allowed for a more direct answer, versus a potential I dont know. The
primary stakeholders that would be most interested in this question include participants
(future) and the principal (as the coordinator).

Question 2: Has the program increased patriotic awareness?

Also, being an outcome-based evaluation question, this again focuses on quantitative
data. This information was gathered through surveys (Appendix B) given to the Patriot Program
participants and an informal test (pass/fail) given to all MM Pierce students to assess their
awareness of specific patriotic tasks listed in the program requirements and comparing the
results of the participants to those of non-participants. This also seemed to be the most direct
route to establish data from this age group. The principal would be the primary stakeholder
that would find this information the most useful, but also the instructional assistants who lead

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the Patriot Club may find this data beneficial to determine their effectiveness in assisting
Patriot Program students in task completion.

Question 3: Is the program accessible to the students?

This evaluation question, for the use of this specific evaluation, is being based on
program outcomes, but for future continuation of the Patriot Program, it could apply in a
formative fashion. Qualitative data was gathered for this question through open-ended
questions on a survey (Appendix B) to allow students to express their own opinions, but also
quantitative data was obtained through close-ended questions on the same survey. The openended responses were very basic, and sometimes non-applicable, depending on the age of the
respondent. The primary stakeholder most interested in this data would be the principal as the
coordinator of the event and the participants to know whether they wish to join and/or
continue with the Patriot Program.

Section 4: type of data, data collection methods, and data analysis techniques used to
answer/address each question
Question 1: Are the participants satisfied with the program?
Quantitative data from close-ended survey question responses (Appendix B) was used
to address this question. Twenty-eight participants, including students from grades one through
five, completed the survey in late April 2014. These students were pulled aside during the
regular school day, the project was explained to them briefly so that they would understand the
reasoning behind being asked to complete the survey, and each student was asked specifically

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and agreed to participate. Survey-takers were asked to not discuss their responses with others
and to work individually, however, the first grade students needed the questions read to them
for assistance.
Once the surveys were completed, the results were reviewed by grade level and as a
whole. The close-ended questions were presented as a Likert scale (strongly agree, agree,
disagree, or strongly disagree). Each rating was assigned a number (strongly agree = 4, agree =
3, disagree = 2, and strongly disagree = 1). The checkmarks that the survey respondents used
were tallied in each question and using the assigned number and combined tallies, the standard
deviation (for strongly agree) and mean (for the overall score) was determined. The mode
was also determined for each question.

Figure 4.1
8
7
6
5
4
3
2
1
0

Grade 1
Grade 2
Grade 3
Grade 4
I enjoyed I was excited I enjoyed
being part of to work on
doing the
the Patriot the Patriot community
Program this Program
service
year
assignments
activites

I would
I hope to
recommend participate in
the Patriot the Patriot
Program to
Program
my friends
again next
next year year if I am a
student at
MM Pierce

Grade 5
Standard Deviation
Mean

Figure 4.1 shows five selected survey questions with results by grade level based on indications
of strongly agree responses.

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Figure 4.2
20
18
16
14
12
10
8
6
4
2
0

Combined Data
Mean
I enjoyed
I was excited
I enjoyed
I would
I hope to
being part of to work on the doing the
recommend participate in
the Patriot
Patriot
community
the Patriot
the Patriot
Program this
Program
service
Program to my Program again
year
assignments activities for friends next next year if I
the Patriot
year
am a student
Program
at MM Pierce

Figure 4.2 shows the combined data from the strongly agree tallies including responses from
survey participants in grades one through five.

Results from the surveys indicate a satisfaction with the Patriot Program. From the
questions that were used in Figures 4.1 and 4.2, strongly agree was the most often chosen
result overall. Strongly agree was also the most frequently chosen result for those five
questions with survey participants in grades 1 and 2. Grade 3 survey participants chose agree
for these questions with the exception of the last one. Strongly agree was the most common
for grade 4 participants for all except the fourth question, in which agree was the most
frequent. For grade 5, survey participants chose strongly agree most frequently with the
exception that the last question had equal votes for strongly agree, agree, and disagree.

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Question 2: Has the program increased patriotic awareness?

The quantitative data used to answer this question was gathered through the same
survey that was used for question 1 and through an informal test of specific tasks. The survey
had one question designed specifically to address student awareness. Using a Likert scale of
strongly agree, agree, disagree, and strongly disagree, the respondents were asked to
choose their agreement to the statement The Patriot Program helped me to learn more about
what it means to be a good citizen. The scale was rated the same way as described previously
for question 1.

Figure 4.3
6
5
Grade 1
4

Grade 2
Grade 3

Grade 4
2

Grade 5

Mean
Standard Deviation

0
The Patriot Program helped me to learn more about what it means to
be a good citizen.

Figure 4.3 shows the responses to the survey question throughout the grade levels, along with
the mean and the standard deviation.

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During music class, every student at MM Pierce Elementary, who was present during
school on their music day, was given an informal test of at least one task that the students
enrolled in the Patriot Program within the same grade level are required to complete. This was
a pass/fail activity in which the students were either marked as knowing it, in its entirety, or
not. The following charts show the results.

Figure 4.4

Preschool
20%

Students in Class
80%

Students who
passed

Figure 4.4 indicates the results for the preschool class and their ability to recite the Pledge of
Allegiance. It should be noted that all 8 of the students in this classroom are special needs and
have Individualized Education Plans.

Figure 4.5

Kindergarten
Students in Class
42%
58%

Students who
Passed

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Figure 4.5 indicates that 42% of the tested kindergarteners were able to recite the Pledge of
Allegiance from memory.

Figure 4.6

First Grade
9%

47%

Students in Class
Students who Passed
Both Tests

34%

44%

10%

Students who Passed

Test 1

Figure 4.6 indicates that 34%of the students were able to recite the Pledge of Allegiance from
memory (Test 1) and 10% could sing My Country Tis of Thee (Test 2), with 9% being able to do
both successfully.

Figure 4.7

Second Grade
15%
Students in Class

34%
36%

49%
15%

Students who Passed

Both Tests

Shaffer 15

Figure 4.7 shows that 34% of the students could recite the Pledge of Allegiance (Test 1) and
15% of the students could sing Youre a Hero (Test 2), with only 15% people able to do both
successfully.

Figure 4.8

Third Grade
10%
39%
40%

Students in Class

50%
11%

Students who
Passed Both Tests

Figure 4.8 shows that 39% of the students could recite the Pledge of Allegiance (Test 1) and
11% could sing My Country Tis of Thee (Test 2), with only 10% being able to do both
successfully.

Figure 4.9

Fourth Grade
0%

Students in Class
50%

50%

50%
0%

Students who
Passed Both Tests
Students who
Passed Test 1

Figure 4.9 shows that 100% of the students were able to recite the Pledge of Allegiance from
memory and 0% were able to sing Carry Me Back to Ole Virginny, meaning that 0% of the

Shaffer 16

students were able to pass both tests. It should be noted that only 2 students in the entire
fourth grade mentioned having ever heard the song before this test.

Figure 4.10

Fifth Grade
16%
Students in Class

34%
34%

50%
16%

Students who
Passed Both Tests

Figure 4.10 shows that 34% of the students were able to recite the Pledge of Allegiance from
memory (Test 1) and 16% were able to sing The Star-Spangled Banner (Test 2), while only 16%
were able to pass both tests successfully.

Figure 4.11
10
9
8
7
6
5
4
3
2
1
0

Both Tests
Test 1
Test 2

First Grade Second Grade Third Grade Fourth Grade Fifth Grade

Figure 4.11 shows the scores of the students who are enrolled in Patriot Club and passed both
tests and/or test 1 and/or test 2 for their respective grade levels.

Shaffer 17

The results for evaluation question 2 indicate that students have not shown a
measurable increase in Patriotic awareness as a result of the Patriot Program. Students enrolled
in the program did not perform any more strongly or differently than those not enrolled in the
program.

Question 3: Is the program accessible to the students?

The qualitative data gathered through open-ended questions on the same survey as
mentioned for evaluation questions 1 and 2 were used to gather data for this evaluation
question. There were four questions that the respondents were asked to complete. One
respondent in second grade left them all blank, thus they were considered no response
answers. The first grade respondents had the questions read to them by the evaluator and
explanations were provided, if needed. Prompting for a particular answer was not used, but if
students seemed confused or uncertain, they were told that they could write I dont know as
their answer. The following charts show the responses to the four open-ended questions.

Figure 4.12

I decided to participate in the Patriot Program

this year because...
5
4
3
2
1
0
Fun/Likable
First Grade

Help Others
Second Grade

No Answer/I don't
know

Third Grade

Fourth Grade

Other
Fifth Grade

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Figure 4.12 indicates, overall, that fun/likable was the most popular response with 13 total
answers. For example: I did it last year and the year before and I really enjoyed it. Responses
in the other category were ones that did not apply to the question, such as I am a strong,
independent student. These responses were likely a result of a misunderstanding of the
question.

Figure 4.13

My favorite part of the Patriot Program is...

8
6
4
2
0
Community Service
First Grade

Projects/Activities

Second Grade

Third Grade

No Answer/I don't know

Fourth Grade

Fifth Grade

Figure 4.13 indicates that community service was the most favorite aspect of the
respondents. For example: My community service because it helps other people.

Figure 4.14

My least favorite part of the Patriot Program is...

6
4
2
0
Nothing
First Grade

Failure
Second Grade

Projects/Activities
Third Grade

No Answer/I don't
know

Fourth Grade

Fifth Grade

Shaffer 19

Figure 4.14 indicates that the projects/activities were the least favorite of the respondents.
For example: Making the maps and labeling them. However, nothing was only one response
lower (i.e. Nothing. I love it!).

Figure 4.15

If I could improve something in the Patriot Program, it

would be...
5
4
3
2
1
0
Nothing
First Grade

More Involvement No Answer/I don't

know
Second Grade

Third Grade

Everything
Fourth Grade

Other
Fifth Grade

Figure 4.15 indicates that more involvement was the top response. For example: improve on
how I do my work and doing better at the program. The one response for everything was
from a first grade student. This response could possibly also be listed under other as it was an
abnormal response to the question. An example of an other response: Nothing. I think Im a
great person and great at doing this.

Shaffer 20

Figure 4.16
7
6
5
4
3
2
1
0

First Grade
Second Grade
Third Grade
Fourth Grade
I feel like I
have done my
best to do the
tasks in the
Patriot
Program.

I was able to I had enough

The
get help from
time to
assignments
other people if complete the were just right
I needed it to assignments.
for me.
complete my
assignments.

Fifth Grade
Standard Deviation
Mean

Figure 4.16 shows the responses to four close-ended questions using a Likert-scale response.
The graph indicates the strongly agree tallies from each grade level.

Using the quantitative and qualitative data gathered, the accessibility of the program to
the students seems to be at an acceptable level. Most respondents marked strongly agree or
agree on the close-ended questions and many of the open-ended questions were positive. It
should also be noted that 7 survey respondents indicated that they were part of the Patriot
Club, 15 said they were not, and 6 did not respond. In response to the question of whether
Patriot Club participants felt more time was needed, 9 respondents said yes, 5 indicated no,
and 14 left it blank. Thirteen respondents said they were part of the Patriot Program last year,
11 said they were not, and 4 did not answer.
This information is vague and does not cover the entire Patriot Program enrollment, but
does seem to indicate that slightly more females than males participate, mostly Caucasian
students, most of the participants are not part of the Patriot Club, but those that are would like
more time, and an almost equal amount of the respondents were in the Patriot Program last

Shaffer 21

year. From this data, it does not seem that there is a wide diversity of the population being
reached.

Section 5: Summary of findings (evaluation results) and recommendations based on findings

Overall, based on these three evaluation questions, it would seem that the Patriot
Program is doing well. The participants, from those involved this school year that were
surveyed, do seem satisfied and do seem to think that the assignments and program are
accessible to their individual needs. However, evaluation question 2 is more inconclusive. There
does not seem to be a stronger patriotic awareness among those in the program versus out of
the program, using the program tasks as the baseline. The findings do seem favorable for the
Patriot Program.
The results from this evaluation could be used by the Patriot Program sponsor (the
school principal) as a tool for any alterations to program assignments in future years to make it
more accessible, more useful, and more effective to participants. Stakeholders could use this
information in different ways. The participants, being elementary students, would not likely be
made aware of the results directly, but could potentially see the results of the evaluation based
on any changes that may occur. Patriot Club sponsors could also use the results to alter their
actions and activities to better accommodate student needs in completion of program tasks
and promotion of patriotic awareness.
There are a few recommendations for future use of the Patriot Program. First, many of
the students, when asked about their participation, did not even know that they were part of
the program (i.e. they did not recognize the name Patriot Program). The possibility does exist

Shaffer 22

that the parents of the students signed them up for the program and the students were never
made aware of the actual program name. It seems that it would be beneficial for them to know
this information. Second, the program tasks for each grade level (first through fifth) include a
song that the guidelines indicate will be performed at the Patriot Assembly to conclude the
year-long Patriot Program assignments. From past years, this has not occurred. The fourth
grade students were not even aware of the song for their grade level. Perhaps a collaboration
with the music department could be established to promote the learning of these songs across
the student body. Also, the morning announcements already include patriotic songs. Instead of
the songs that are currently being used, perhaps the songs that are involved in the Patriot
Program could be played on a rotating basis to promote familiarity. Lastly, community service
was a ver

y popular activity with the surveyed students. This aspect of the program could

be strengthened and made into a larger portion of the overall tasks, either by increasing the
amount of time required or providing other assignments that involve students specifically doing
a community service event.
The students who participate in the Patriot Program seem to enjoy it. It is curious that
the older grade levels have less participation than the younger ones. Perhaps, again, due to
parental enrollment versus student choice. This is a currently unknown factor. Taking the
opportunity to explain and promote the program at the start of the year to the student body
may encourage more enrollment, understanding of the requirements, and overall knowledge.

Shaffer 23

APPENDIX A

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Shaffer 27

APPENDIX B
2013-2014 School Year
This survey has been designed
by Ms. Shaffer to determine
information about the Patriot
Program at M.M. Pierce
Elementary School,
specifically regarding participation, interest, and effectiveness. Do not include your name on this paper
so that identities may be kept confidential. This information will be used to try to improve the Patriot
Programs success and usefulness for the students who participate. Please respond to the best of your
ability with the answer that best applies to you by putting a check mark. Remember to mark only ONE
box for each line.
Grade: PK K 1 2 3 4 5 (circle one)
(Optional) Race: Caucasian

African-American

Gender: Male Female (circle one)

Hispanic

Strongly
Agree
1. I feel like I have done my best to do the
tasks in the Patriot Program.
2. I was able to get help from other people
(my parents, my brothers and sisters, or
others) if I needed it to complete my
Patriot Program assignments.
3. The Patriot Program helped me to learn
more about what it means to be a good
citizen.
4. I had enough time to complete the
assignments for the Patriot Program.
5. I enjoyed being part of the Patriot
Program this year.
6. The assignments for the Patriot
Program were just right for me (not too
hard, not too easy).
7. I was excited to work on the Patriot
Program assignments.
8. I enjoyed doing the community service
activities for the Patriot Program.
9. I would recommend the Patriot
Program to my friends next year.
10. I hope to participate in the Patriot
Program again next year if I am a student
at MM Pierce.

Asian

Other:___________ (circle all that apply)

Agree

Disagree

Strongly
Disagree

Shaffer 28

I am also part of the Patriot Club that meets before school on some days: Yes

No (circle one)

If you answered yes to the above question, please answer the following question also:
I think that the Patriot Club should meet more often: Yes

No (circle one)

I was part of the Patriot Program last year at MM Pierce, too: Yes

No (circle one)

I decided to participate in the Patriot Program this year because ________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

My favorite part of the Patriot Program is ___________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

My least favorite part of the Patriot Program is ______________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

If I could improve something in the Patriot Program, it would be ________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
Date Completed: ___________________________